YOUR GROUP BASIC LIFE & MONTHLY DISABILITY INCOME INSURANCE PLAN

Transcription

1 YOUR GROUP BASIC LIFE & MONTHLY DISABILITY INCOME INSURANCE PLAN For Employees of Kalispell School District #5 6CC000 B (12-14)

2 CONTENTS LIFE INSURANCE CERTIFICATION PAGE SCHEDULE OF BENEFITS Basic Life and Accidental Death and Dismemberment (AD&D) Insurance Proof of Good Health EMPLOYEE'S INSURANCE LIFE INSURANCE Waiver of Life Insurance Premium Disability Benefit Accelerated Death Benefit Accidental Death & Dismemberment (AD&D) Insurance CONVERSION RIGHTS CLAIM PROCEDURES GENERAL PROVISIONS DEFINITIONS DISABILITY INCOME CERTIFICATION PAGE SCHEDULE OF BENEFITS Disability Income Insurance Monthly Income Benefits EMPLOYEE'S INSURANCE DISABILITY INCOME INSURANCE Monthly Income Benefits CLAIM PROCEDURES GENERAL PROVISIONS DEFINITIONS LC00GP (MT rev 8/07) B (12-14) i

3 SECTION I LIFE INSURANCE 1

4 RELIASTAR LIFE INSURANCE COMPANY Minneapolis, Minnesota ReliaStar Life Insurance Company (ReliaStar Life) certifies that it has issued the Group Policy listed below to the Policyholder. All benefits are controlled by the terms and conditions of the Group Policy. The Group Policy is on file in the Policyholder's office. You may look at the Group Policy there. Group Policy Number GAT Policyholder Kalispell School District Your beneficiary is the last beneficiary you named, according to the records on file in ReliaStar Life's Home Office or on file with the Plan Administrator, if applicable. You may change your beneficiary any time, according to the terms of the Group Policy. The certificate summarizes and explains the parts of the Group Policy which apply to you. This certificate is not an insurance policy. In any case of differences or errors, the Group Policy rules. This certificate replaces any other certificates ReliaStar Life may have given you under the Group Policy. Registrar 2

5 SCHEDULE OF BENEFITS Basic Life and Accidental Death and Dismemberment (AD&D) Insurance Class Amount of Life Insurance* Full Amount of AD&D Insurance* Kalispell Active Employees $15,000 $15,000 Kalispell Administrative Staff $115,000 $115,000 Retirees An amount of insurance reported to ReliaStar Life by the Policyholder None Employees approved for portability Approved ported amount, but the total amount of ported Basic and Supplemental Life will not exceed the lesser of 5 times Basic Yearly Earnings or $750,000** Approved ported amount, not to exceed ported Life amount** *Your amount of insurance will decrease to 50% on your 70th birthday. **Your minimum amount of ported coverage, including decreases, is $5,000 total Life Insurance and $5,000 total AD&D Insurance. Basic Yearly Earnings the yearly salary or wage you receive for work done for the Policyholder. It does not include bonuses, commissions or overtime pay. To determine benefits, your amount of insurance is rounded to the next higher $1,000 multiple unless the amount equals a multiple of $1,000. Accelerated Death Benefit This benefit is equal to 75% of your amount of Life Insurance in force, or $500,000, whichever is less. This benefit is available to employees only. Employees must have at least $10,000 in Life Insurance coverage in force to qualify for this benefit. Proof of Good Health Proof of good health is required for amounts in excess of the limits described below. Coverage is subject to the Group Policy's proof of good health requirements that are in force on the effective date of coverage. Any increase to coverage is subject to the Group Policy's proof of good health requirements that are in force on the effective date of the increase. For proof of good health, a completed Evidence of Insurability form must be submitted to ReliaStar Life for approval. Employee-Basic Life Insurance Coverage on the Group Policy Effective Date continued from the Policyholder's prior plan... Initial Eligibility after the Group Policy Effective Date... Increases due to salary, job or class changes, that combined with existing coverage do not exceed $115, Limit without Proof Current amount, up to $115,000 $115,000 Amount of the increase 3

6 EMPLOYEE'S INSURANCE Eligibility You are eligible on the later of the following dates: The Group Policy's Effective Date, October 1, The first day of the month on or after the date you start continuous service with the Policyholder. You must meet the following conditions to become insured: Be eligible for the insurance. Be actively at work. Give to ReliaStar Life proof of good health, which it approves, as required on the Schedule of Benefits. Effective Date of Employee's Insurance Your insurance starts on the latest of the following dates: The date you become eligible. The date you return to active work if you are not actively at work on the date insurance would otherwise start. Exception: Your insurance starts on a nonworking day if you were actively at work on your last scheduled working day before the nonworking day. The date ReliaStar Life approves your proof of good health, if proof is required. Effective Date of Change in Amount of Insurance If there is an increase in the amount of your insurance, the increase will take effect on: The date of the increase, if you are actively at work on that date. The date you return to active work, if you are not actively at work on the date your insurance increases. The nonworking day on which the increase was effective, if you were actively at work on your last scheduled working day before the nonworking day. A decrease in the amount of your insurance will take effect on the date of the decrease. Termination of Insurance Your insurance stops on the earliest of the following dates: For coverage not ported, the last day of the month during which you were last actively at work for the Policyholder. For coverage not ported, the last day of the month during which you are no longer eligible for insurance under the Group Policy. For coverage not ported, the last day of the month during which you retire, unless you are eligible for retiree life insurance. The end of the period for which you paid premiums, if you do not make the next required premium contribution when due. The date the Policyholder replaces the Life Insurance under this plan with a similar life insurance plan through another insurance carrier, if you are actively at work for the Policyholder on that date. The date the Group Policy terminates. For ported Life Insurance, the date you attain age 80. For ported AD&D Insurance, the date you attain age 70. For all AD&D Insurance, the date your Life Insurance terminates or the date your Life Insurance premiums are waived due to total disability. For coverage not ported, AD&D Insurance stops at the beginning of the period in which you are eligible to convert your Life Insurance. For Accelerated Death Benefit, the date your Life Insurance terminates. For coverage not ported, the Accelerated Death Benefit stops at the beginning of the period in which you are eligible to convert your Life Insurance. For Accelerated Death Benefit on ported Life Insurance, the date you attain age 70. ReliaStar Life stops providing a specific benefit to you on the date that benefit is no longer provided under the Group Policy. Family and Medical Leave Act of 1993 Certain employers are subject to the FMLA. If you have a leave from active work certified by your employer, then for purposes of eligibility and termination of coverage you will be considered to be actively at work. Your coverage will remain in force so long as you continue to meet the requirements as set forth in the FMLA. 4

7 EMPLOYEE'S INSURANCE Continuation of Life Insurance If you are no longer eligible for Life Insurance because you stop active work, the Policyholder may continue your insurance. Premiums must be paid. Your continuation of insurance is subject to all other terms of the Group Policy. The length of time your insurance continues depends on the reason you stop active work. Your continuation of insurance stops on the earliest of the following dates: The end of the period for which your premiums were paid, if the next premium contribution is not paid on time. The date the Group Policy stops. The end of the 12th policy month after the policy month during which you stop active work, if you stop active work due to non-medical leave of absence, temporary layoff, or the Policyholder suspending operations. The date you attain age 65, if you stop active work due to sickness or accidental injury. The date your Life Insurance has been continued for 12 months, if you stop active work due to sickness or accidental injury, The date you are no longer totally disabled, if you are totally disabled on the date you stop active work. The date you do not provide proof of total disability when asked, if you are totally disabled on the date you stop active work. If your continuation of insurance stops and you are no longer eligible for Employee's Insurance under the Group Policy, then you will be eligible for conversion as described in the Conversion Rights section. Portability You can apply to continue your terminated Basic Life and AD&D Insurance until age 80 if certain conditions are met. AD&D Insurance may only be ported if Life Insurance is ported, and before you reach age 70. You may elect to decrease your ported coverage. You will not be eligible to increase your ported coverage. The minimum amount of your Life Insurance that you can apply to port is $5,000. See the Schedule of Benefits for maximum amounts. If your total amount of terminated Life Insurance otherwise eligible to be ported is less than $5,000, then you may be eligible for conversion as described in the Conversion Rights section. You must apply for portability within 31 days of the date your insurance terminates due to the following: You terminate employment with the Policyholder, if coverage is in effect for active employees under the Group Policy; or The Policyholder terminates Basic Life Insurance for active employees under the Group Policy and does not replace it with a similar life insurance plan; or You are no longer eligible for Employee's Insurance under the Group Policy; or All other continuation under the Group Policy ends. If your amount of insurance reduces due to age or a change in employment status, this is not considered a termination of insurance for purposes of portability. Please refer to the Conversion Rights section for more information about conversion following reductions in coverage. Your application for portability is subject to approval by ReliaStar Life. If you are not approved for portability, you may still be eligible for conversion as described in the Conversion Rights section. The Incontestability provision in the General Provisions section also applies to ported coverage starting with the effective date of your ported coverage and continuing for two years while you are living. If you port coverage and then later become eligible as an active employee for Employee's Insurance under a Group Policy issued by ReliaStar Life, then your amount of ported coverage will be reduced by your amount of insurance as an active employee. Please refer to the Conversion Rights section for information about conversion following termination of coverage that is continued under the portability option. 5

8 LIFE INSURANCE Employee's Life Insurance ReliaStar Life pays a death benefit to your beneficiary if written proof is received that you have died while this insurance is in force. The death benefit is the amount of Life Insurance for your class shown on the Schedule of Benefits in effect on the date of your death. ReliaStar Life pays the death benefit within 60 days after receiving written proof of your death. ReliaStar Life will include interest from at least the 30th day until the date of payment. ReliaStar Life will pay interest, at a minimum, at the discount rate on 90-day commercial paper in effect at the Federal Reserve Bank in the Ninth Federal Reserve District at the time of receipt of death. ReliaStar Life pays the death benefit for all causes of death. Beneficiary The beneficiary is named to receive the proceeds to be paid at your death. You may name more than one beneficiary. The Policyholder cannot be the beneficiary. You may name, add or change beneficiaries by written request as described below. You may also choose to name a beneficiary that you cannot change without his or her consent. This is an irrevocable beneficiary. You may name, add or change beneficiaries by written request if all of the following conditions are met: Your coverage is in force. ReliaStar Life has written consent of all irrevocable beneficiaries. You have not assigned the ownership of your insurance. The rights of an assignee are described in the Assignment section. All requests are subject to the approval of ReliaStar Life. A change will take effect as of the date it is signed but will not affect any payment ReliaStar Life makes or action it takes before receiving your notice. Payment of Proceeds ReliaStar Life pays proceeds to the beneficiary. If there is more than one beneficiary, each receives an equal share, unless you have requested otherwise, in writing. To receive proceeds, a beneficiary must be living on the earlier of the following dates: The date ReliaStar Life receives proof of your death. The tenth day after your death. If there is no eligible beneficiary or if you did not name one, ReliaStar Life pays the proceeds in the following order: 1. Your spouse or domestic partner. 2. Your natural and adopted children. 3. Your parents. 4. Your estate. The person must be living on the tenth day after your death. Settlement Options Settlement options are alternative ways of paying the proceeds under the Group Policy. Proceeds is the amount of each benefit ReliaStar Life pays when you die or when you receive a lump sum amount under the Accelerated Death Benefit. To find out more about settlement options, please contact the Policyholder. Waiver of Life Insurance Premium Disability Benefit ReliaStar Life waives your Life Insurance premium that becomes due while you are totally disabled. The premium will be waived if you satisfy certain conditions. When ReliaStar Life waives a premium, the amount of Life Insurance equals the amount that would have been provided if you had not become totally disabled. That amount will reduce or stop according to the Schedule of Benefits in effect on the date total disability begins. When ReliaStar Life waives a premium it includes Life Insurance, Accelerated Death Benefit, and Waiver of Premium. It does not include AD&D Insurance, or any other benefits as elected under this certificate which were effective at the time of disability. 6

9 LIFE INSURANCE Conditions, Notice and Proof of Total Disability ReliaStar Life requires written notice of claim and proof of total disability to waive your premium. All of the following conditions must also be met: Total disability must begin before your 60th birthday. You are insured for the Waiver of Life Insurance Premium Disability Benefit on the date you become totally disabled. You continue to be totally disabled. Your insurance is in force when you suffer the sickness or accidental injury causing the total disability. All premiums are paid up to the date the Waiver of Premium is approved by ReliaStar Life. ReliaStar Life needs written notice of claim before it waives any premium. This notice must be received while you are living, while you are totally disabled, and within one year from the date total disability begins. If you cannot give ReliaStar Life notice within one year, your claim is still valid if you show you gave ReliaStar Life notice as soon as reasonably possible. ReliaStar Life needs proof of your total disability before any premiums can be waived. ReliaStar Life may require you to have a physical exam by a doctor it chooses. ReliaStar Life pays for that exam. ReliaStar Life can only require one exam a year after premiums have been waived for 2 full years. When ReliaStar Life approves your proof of total disability, premiums are waived as of the date you became totally disabled. ReliaStar Life refunds, to the Policyholder, any premium paid for a period during which you were totally disabled. It is the Policyholder's responsibility to refund to you any part of the premium you paid. Termination of Waiver of Premium ReliaStar Life stops waiving premiums on the earliest of the following dates: The date you are no longer totally disabled. The date you do not give ReliaStar Life proof of total disability when asked. The date you attain age 65. If ReliaStar Life stops waiving your premiums, your Life Insurance will stay in force only if all of the following conditions are met: The Life Insurance under the Group Policy is still in force. You are eligible for Employee's Insurance under the Group Policy. Your premium payments are resumed. The amount of Life Insurance that stays in force will be the amount shown on the Schedule of Benefits in effect on the date your premium payments are resumed. You will not be eligible to continue insurance under the portability option when ReliaStar Life stops waiving your premiums. If you buy an individual policy under the Conversion Right of the Group Policy during the first year of your total disability, your Life Insurance may be restored. ReliaStar Life will cancel the individual policy as of its issue date if within 12 months of the date you become totally disabled you file a claim under this provision and ReliaStar Life approves it, and surrender the individual policy without claim, except for refund of premium. When ReliaStar Life cancels your individual policy, ReliaStar Life refunds all premiums paid for the individual policy. restores your Life Insurance under the Group Policy. retains the beneficiary named under the individual policy as beneficiary under the Group Policy, unless you ask ReliaStar Life to change the beneficiary in writing. 7

10 LIFE INSURANCE Accelerated Death Benefit NOTE: AT THIS TIME IT IS UNCLEAR WHETHER YOU WILL BE REQUIRED TO PAY TAX ON ACCELERATED DEATH BENEFIT PROCEEDS. YOU SHOULD CONSULT WITH YOUR PERSONAL TAX ADVISER TO ASSESS POSSIBLE TAX IMPLICATIONS. ReliaStar Life pays this benefit if it has been determined that you have a terminal condition. Accelerated Death Benefit proceeds is the amount ReliaStar Life pays to you or your legal representative while you are living when it has been determined that you have a terminal condition. The Accelerated Death Benefit proceeds are paid in one lump sum and are paid only once. This lump sum payout is the only Settlement Option available to you prior to your death. The Accelerated Death Benefit is the amount of the Accelerated Death Benefit shown on the Schedule of Benefits in effect on the date you apply for Accelerated Death Benefit proceeds. You will not be able to increase your contributory Life Insurance benefit after the time you apply for the Accelerated Death Benefit, unless you are determined to be ineligible to receive Accelerated Death Benefit proceeds. To receive the Accelerated Death Benefit, all of the following conditions must be met. You must: request this benefit in writing while you are living. If you are unable to request this benefit yourself, your legal representative may request it for you. be insured as an employee for Life Insurance benefits. have Life Insurance benefits of at least $10,000 as shown on the Schedule of Benefits. provide to ReliaStar Life a doctor's statement which gives the diagnosis of your medical condition; and states that because of the nature and severity of such condition, your life expectancy is no more than 12 months. ReliaStar Life may require that you be examined by a doctor of its choosing. If ReliaStar Life requires this, ReliaStar Life pays for the exam. provide to ReliaStar Life written consent from any irrevocable beneficiary, assignee, and, in community property states, from your spouse. Benefit Payment ReliaStar Life pays the Accelerated Death Benefit proceeds to you unless both of the following are true: It is shown, to the satisfaction of ReliaStar Life, that you are physically and mentally incapable of receiving and cashing the lump sum payment. A representative appointed by the courts to act on your behalf does not make a claim for the payment. If ReliaStar Life does not pay you because the two above conditions apply, payments instead will be made to one of the following: A person who takes care of you. An institution that takes care of you. Any other person ReliaStar Life considers entitled to receive the payments as your trustee. Accelerated Death Benefit Exclusions ReliaStar Life does not pay benefits for a terminal condition if either of the following apply: the required Accelerated Death Benefit premium or Life Insurance premium is due and unpaid. the terminal condition is directly or indirectly caused by attempted suicide or intentionally self-inflicted injury, whether sane or insane. Effects on Coverage When ReliaStar Life pays out this benefit, your coverage is affected in the following ways: Your total available Life Insurance benefit equals your amount of Life Insurance shown on the Schedule of Benefits at the time you apply for the Accelerated Death Benefit. Your Life Insurance benefit is reduced by the Accelerated Death Benefit proceeds paid out under this provision. Your Life Insurance benefit amount which you may convert is reduced by the Accelerated Death Benefit proceeds paid out under this provision. You will not be able to increase your Life Insurance benefit after ReliaStar Life approves you to receive the Accelerated Death Benefit. Your premium is based upon the Life Insurance benefit amount in force prior to any proceeds paid under this Accelerated Death Benefit provision. Such premium must be paid, unless waived, to keep the Life Insurance coverage in force. Your remaining Life Insurance benefit is subject to future age reductions, if any, as shown on the Schedule of Benefits. 8

11 LIFE INSURANCE You will not be able to reinstate your coverage to its full amount in the event of a recovery from a terminal condition. Your receipt of Accelerated Death Benefit proceeds does not affect your Accidental Death and Dismemberment Insurance. Thus, if you should die in an accident after receiving Accelerated Death Benefit Proceeds, your Accidental Death and Dismemberment Insurance will be based on your Life Insurance in force prior to the Accelerated Death Benefit payout, provided your premium is not being waived. Accidental Death & Dismemberment (AD&D) Insurance ReliaStar Life pays this benefit if you suffer a covered loss due to a covered accident. All of the following conditions must be met: You are covered for AD&D Insurance on the date of the accident. Loss occurs within 180 days of the date of the accident. The cause of the loss is not excluded. ReliaStar Life pays the benefit shown on the Table of AD&D Benefits if you suffer any of the losses listed. For loss of life, ReliaStar Life pays the benefits within 60 days after receiving written proof of your death. ReliaStar Life will include interest from at least the 30th day until the date of payment. ReliaStar Life will pay interest, at a minimum, at the discount rate on 90-day commercial paper in effect at the Federal Reserve Bank in the Ninth Federal Reserve District at the time of receipt of proof of death. ReliaStar Life pays only one Full Amount in total while the Group Policy is in effect. If you have a loss for which we pay 1/2 the Full Amount, ReliaStar Life pays no more than 1/2 the Full Amount for the next loss. After ReliaStar Life has paid one Full Amount, no further benefits are payable under this AD&D Insurance. For: The benefit is: Loss of life... Full Amount Loss of both hands, both feet or sight of both eyes... Full Amount Loss of one hand and one foot... Full Amount Loss of speech and hearing in both ears... Full Amount Loss of one hand or one foot and sight of one eye... Full Amount Loss of one hand or one foot or sight of one eye... ½ Full Amount Loss of speech... ¼ Full Amount Loss of hearing in both ears... ¼ Full Amount Loss of thumb and index finger of same hand... ¼ Full Amount Quadriplegia... Full Amount Paraplegia... ½ Full Amount Hemiplegia... ½ Full Amount Loss of hands or feet means loss by being permanently, physically severed at or above the wrist or ankle. Loss of sight means total and permanent loss of sight. Loss of speech and hearing means total and permanent loss of speech and hearing. Loss of thumb and index finger means loss by being permanently, physically, entirely severed. Quadriplegia means total paralysis of all four limbs. Paraplegia means total paralysis of both lower limbs. Hemiplegia means paralysis of one arm and one leg on the same side of the body. Paralysis must be the result of a spinal cord injury which is due to an accident. ReliaStar Life does not pay an AD&D benefit for any paralysis caused by a stroke. Paralysis must be determined by competent medical authority to be permanent, complete and irreversible. ReliaStar Life does not pay a benefit for loss of use of the hand or foot or thumb and index finger. Death benefits are paid to your beneficiary. All other benefits are paid to you. 9

12 LIFE INSURANCE Exposure and Disappearance Benefit ReliaStar Life pays an Exposure benefit if: the loss is from injury caused by exposure to the elements, and is the result of a covered accident. ReliaStar Life pays a Disappearance benefit if: you are in a conveyance, including but not limited to an automobile, airplane, ship or train, that disappears, sinks or wrecks; and you disappear and your body is not found, and the disappearance is the result of a covered accident; and a reasonable period of time, but no more than one year, has lapsed since the accident, and ReliaStar Life has reviewed all evidence and there is no reason to believe that you are living. The amount payable for the Exposure benefit is contained in the table above. The amount payable for the Disappearance benefit is the AD&D benefit for loss of life. If benefits are paid for Exposure or Disappearance, no other AD&D benefits will be payable under the Group Policy. Exposure benefits are paid to you if living, otherwise to your beneficiary. Disappearance benefits are paid to your beneficiary. If ReliaStar Life pays the Disappearance benefit and it is later found you are alive, the amount of benefits paid must be refunded to ReliaStar Life. Safe Driver Benefit ReliaStar Life pays a Safe Driver benefit in addition to the AD&D benefit and subject to the exclusions listed below if you were: killed due to an automobile accident, and wearing a properly fastened safety belt at the time of the accident. An additional amount will be paid if you were also driving in or riding in an automobile equipped with a factory installed airbag that operated properly upon impact. For loss of: The benefit is: Life (with safety belt only)... An additional 10% of Full Amount of AD&D Insurance up to a maximum of $25,000 Life (with safety belt and airbag)... An additional 15% of Full Amount of AD&D Insurance up to a maximum of $40,000 Automobile means any self-propelled private passenger vehicle which has four or more tires and which is not being used for commercial purposes. Safety belt means a passenger restraint system properly installed in the vehicle in which you were riding. Airbag means an additional restraint system which inflates for added protection to the head and chest areas. ReliaStar Life will not pay the Safe Driver benefit if the loss of life was caused directly or indirectly by any use of intoxicating liquors, marijuana, narcotic drugs, depressants or similar substances, whether or not prescribed by a doctor, by you or by the driver of the automobile in which you were riding. Safe Driver benefits are paid to your beneficiary. Coma Benefit ReliaStar Life pays a Coma benefit if, due to an accident, you are in a coma. Coma benefit payments will stop when you are no longer in a coma or when maximum benefits have been paid, whichever comes first. In the event of: The benefit is: Coma... An additional 2% of Full Amount of AD&D Insurance per month for up to 12 months to a total maximum of $24,000 10

13 LIFE INSURANCE Coma means that you remain unresponsive to any stimuli and speechless for a period of time not less than 30 days, as determined by a competent medical authority. If you are physically and mentally incapable of receiving and cashing Coma benefit payments, then the payments instead will be made to a person legally authorized to receive the payments on your behalf. Education Benefit ReliaStar Life pays an Education benefit in addition to the AD&D benefit and subject to the conditions below if you die due to an accident. This benefit will be paid at the end of each annual period following your death to your dependent who is enrolled as a full-time student in an accredited post-secondary institution of higher learning beyond grade 12 within 365 days following the date of your death. Benefit payments will stop if either of the following is true during the preceding annual period the student's full-time school attendance is less than 6 months; or the student would no longer be considered your eligible dependent under the definition of dependent in the policy. For: The benefit is: Education... An additional 5% of Full Amount of AD&D Insurance per year for up to 4 years to a maximum of $3,000 per year Education benefits are paid to each eligible dependent student, or to the dependent's legal guardian. Transportation Benefit ReliaStar Life pays a Transportation benefit in addition to the AD&D benefit if you die due to an accident that occurs at least 75 miles from your primary residence. For: The benefit is: Transportation... An additional 2% of Full Amount of AD&D Insurance up to a maximum of $2,000 Transportation benefits are paid to your beneficiary. Child Care Benefit ReliaStar Life pays a Child Care benefit in addition to the AD&D benefit if you die due to an accident, and your dependent child under age 13 years is enrolled in a licensed day care center within 90 days of your death. This benefit is paid on behalf of each eligible dependent child at the end of each annual period following your death. Benefit payments will stop if either of the following is true during the preceding annual period your dependent child does not attend a licensed day care center for at least 1000 hours; or your dependent child is not under age 13 years for any part of that year. For: The benefit is: Child Care... An additional 3% of Full Amount of AD&D Insurance per year for up to 6 years to a maximum of $2,000 per year Child Care benefits are paid to the person who has incurred the cost of day care expenses for your eligible dependent child. Occupational Assault Benefit ReliaStar Life pays an Occupational Assault benefit in addition to the AD&D benefit if you suffer a covered loss due to an accident, and: the loss is due to an intentional and unlawful act of physical violence directed at you by another person, you are actively at work, performing assigned duties on behalf of the Policyholder at the time of the assault, and 11

14 LIFE INSURANCE a report of criminal activity has been filed on your behalf with the appropriate law enforcement authority within 48 hours of the assault. For loss due to: The benefit is: Occupational Assault... An additional AD&D Amount equal to the AD&D amount otherwise payable for this loss up to a maximum of $10,000 Occupational Assault benefits are paid to you if living, otherwise to your beneficiary. Accidental Death and Dismemberment Exclusions ReliaStar Life does not pay benefits for loss directly or indirectly caused by any of the following: Suicide or intentionally self-inflicted injury, while sane or insane. Physical or mental illness. Bacterial infection or bacterial poisoning. Exception: Infection from a cut or wound caused by an accident. Riding in or descending from an aircraft as a pilot or crew member. Any armed conflict, whether declared as war or not, involving any country or government. Injury suffered while in the military service for any country or government. Injury which occurs when you commit or attempt to commit a felony. Voluntary use of any drug, narcotic or hallucinogenic agent unless prescribed by a doctor. which is illegal. not taken as directed by a doctor or the manufacturer. Your intoxication. Intoxication means your blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred. 12

15 CONVERSION RIGHTS Life Insurance You may convert this insurance to an individual life insurance policy if any part of your Life Insurance under the Group Policy stops. Proof of good health is not required. Conditions for Conversion You may convert Life Insurance if it terminates for any of the following reasons: For coverage not ported, you are no longer actively at work. For coverage not ported, you are no longer eligible for Employee's Insurance under the Group Policy. For ported coverage, you have reached the termination age under the Group Policy. The Group Policy is changed or cancelled, and your Life Insurance under the Group Policy has been in effect for at least 3 years in a row. Your premiums are no longer being waived due to total disability, and your group Life Insurance terminates. For your Life Insurance, the amount of insurance is reduced. You may convert this insurance by applying and paying the first premium for an individual policy within 31 days after any part of your insurance stops. If you are not given written notice of this conversion right within 16 days after any part of this insurance stops, you will have more time to apply and pay the first premium for the individual policy. This additional time period will end 15 days after you are given written notice of this conversion right. In no event will the additional time period extend for more than 91 days after any part of your Life Insurance stops. ReliaStar Life or the Policyholder must be notified if you wish to convert. ReliaStar Life will supply you with a conversion form to complete and return. Type of Converted Policy You may purchase any individual nonparticipating policy offered by ReliaStar Life, except term insurance. The new policy must provide for a level amount of insurance and have premiums at least equal to those of ReliaStar Life's whole life plan with the lowest premium. If your previous coverage included additional benefits such as disability, Accidental Death and Dismemberment Insurance or the Accelerated Death Benefit, the new insurance will not include these benefits. Amount of Conversion Coverage If your Life Insurance is changed or cancelled because the Group Policy is changed or cancelled, and your Life Insurance under the Group Policy has been in effect for at least 3 years in a row, the amount of the individual policy is limited to the lesser of $10,000, or the amount of your Life Insurance which stops, minus the amount of other group insurance for which you become eligible, within 31 days of the date your insurance stops. If your Life Insurance stops for any reason other than the above, the amount of your individual policy may be any amount up to the amount of your Life Insurance that stopped. Effective Date The new policy takes effect 31 days after the part of your Life Insurance being converted stops. If you die within the 31-day period allowed for making application to convert, ReliaStar Life will pay a death benefit to your beneficiary in the amount you were entitled to convert. ReliaStar Life will pay the amount whether or not application was made. ReliaStar Life will return any premium paid for the individual policy to your beneficiary named under the Group Policy. Premiums Premiums for the new policy are based on your age on the date of conversion. 13

16 CLAIM PROCEDURES Submitting a Claim You or someone on your behalf must send ReliaStar Life written notice of the loss on which your claim will be based. The notice must include information to identify you, like your name, address and Group Policy number. be sent to ReliaStar Life or to the authorized administrator. be sent within 91 days after the loss for which claim is based has occurred or as soon as reasonably possible. Claim Forms ReliaStar Life or its authorized administrator will send proof of loss claim forms within 15 days after ReliaStar Life receives notice of claim. Completed proof of loss claim forms or other written proof of loss detailing how the loss occurred must be sent to ReliaStar Life within 91 days after the loss or as soon as reasonably possible. Benefit Payments Benefits under the Group Policy are paid when proof of loss is received. For Life Insurance, benefits payable due to death will be paid within 60 days of the date ReliaStar Life receives proof of death. If payment is made after the first 30 days, ReliaStar Life will include interest from the 30th day until the date of payment. The interest rate will equal the greater of the following The discount rate on 90-day commercial paper in effect at the federal reserve bank in the ninth federal reserve district on the date proof of death is received. ReliaStar Life's minimum interest rate payable on death claims on the date proof of death is received. 14

17 GENERAL PROVISIONS Life Insurance Assignment You can change the owner of your Life Insurance under the Group Policy by sending ReliaStar Life written notice. This change is an absolute assignment. You cannot make an absolute assignment to the Policyholder. You transfer all your rights and duties as owner to the new owner. The new owner can then make any change the Group Policy allows. A request for an absolute assignment does not change the insurance or the beneficiary. applies only if ReliaStar Life receives your notice. takes effect from the date signed. does not affect any payment ReliaStar Life makes or action ReliaStar Life takes before receiving your notice. A collateral assignment is not allowed. ReliaStar Life assumes no responsibility for the validity of any assignment. You are responsible to see that the assignment is legal in your state and that it accomplishes the goals that you intend. Legal Action Legal action may not be taken to receive benefits until 60 days after the date proof of loss is submitted according to the requirements of the Group Policy. Legal action must be taken within 3 years after the date proof of loss must be submitted. If the Policyholder's state requires longer time limits, ReliaStar Life will comply with the state's time limits. Exam and Autopsy For AD&D Insurance, when reasonably necessary, ReliaStar Life may have you examined while a claim is pending under the Group Policy. ReliaStar Life pays for the initial exam. ReliaStar Life may have an autopsy made if you die, if not forbidden by state law. Incontestability Your insurance has a contestable period starting with the effective date of your insurance and continuing for 2 years while you are living. During that 2 years, ReliaStar Life can contest the validity of your insurance because of inaccurate or false information received relating to your insurability. Only statements that are in writing and signed by you can be used to contest the insurance. The Group Policy also has a 2 year contestable period starting from the Effective Date of the Group Policy. After the Group Policy has been in force for 2 years from the Effective Date, ReliaStar Life can not contest the validity of the Group Policy except for nonpayment of premium. Grace Period If a premium is not paid by its due date, ReliaStar Life allows 45 days from the due date in which to pay it. ReliaStar Life calls this the grace period. Full payment must be received by the 45th day. If ReliaStar Life receives payment during the grace period, coverage under the Group Policy stays in force. If ReliaStar Life receives written notice of termination during the grace period, premium payment is required for any period that coverage under the Group Policy was in force during the grace period. Representations Not Warranties A copy of the Policyholder's application, if any, is attached to the Group Policy. Unless fraudulent, all statements made by the Policyholder or by you are considered representations and not warranties. No statement can be used to void the Group Policy or be used in ReliaStar Life's defense if ReliaStar Life refuses to pay a claim, unless a copy of the statement is furnished to the Policyholder, you or your beneficiary, as applicable. Misstatement of Age If your is misstated, ReliaStar Life adjusts the premium according to the correct age. The amount of insurance provided is not affected. Conformity with Montana Statutes The provisions of this certificate conform to the minimum requirements of Montana law and control over any conflicting statutes of any state in which you reside on or after the effective date of your coverage under the Group Policy. 15

18 DEFINITIONS Accident an unexpected, external, violent and sudden event. Active Work, Actively at Work the employee is physically present at his or her customary place of employment with the intent and ability of working the scheduled hours and doing the normal duties of his or her job on that day. Dependent your lawful spouse. your domestic partner, as defined. your unmarried child over 14 days but less than 26 years of age. The term dependent does not include a married child. a spouse, domestic partner or child living outside the United States. a spouse, domestic partner or child eligible for Employee's Insurance under the Group Policy. a spouse, domestic partner or child on active military duty. a parent of you or your spouse or domestic partner. a spouse, domestic partner or child who does not give proof of good health when requested, or whose proof is not approved. Domestic Partner another adult with whom you have completed and signed the Policyholder's Affidavit of Domestic Partnership and filed it with the Policyholder attesting that you have registered your Domestic Partnership with a governmental body authorizing such a registration, neither of you are married to anyone and you are the sole partners of each other, you are both at least 18 years of age, you are not related by blood closer than would bar marriage in your State, you are both mentally competent to consent to contract, you share a common residence, you have lived together continuously for at least 12 months, you are in a committed and mutually exclusive relationship, and you meet any other requirements listed in the Affidavit. You must notify the Policyholder in writing if there is any change of circumstances attested to in the Affidavit within 30 days of such change. Employee an active, full-time employee who resides in the United States who the Policyholder employs and pays on at least a 20-hour-per-week, 48-week-per-year basis. A retiree is an employee who retires on a pension plan controlled and administered by the policyholder. All such employees of companies and affiliates controlled by the Policyholder are included. Group Policy the written group insurance contract between ReliaStar Life and the Policyholder. Nonworking Day a day on which the employee is not regularly scheduled to work, including time off for the following: Vacations. Personal holidays. Weekends and holidays. Approved nonmedical leave of absence. Paid Time Off for nonmedical-related absences. Nonworking day does not include time off for any of the following: Medical leave of absence. Time off for a medical leave of absence will be considered a scheduled working day. Temporary layoff. The Policyholder suspending its operations, in part or total. Strike. Policyholder Kalispell School District #5 Portability the option for you to elect to continue your insurance under the Group Policy after the date it would otherwise terminate. Please refer to the Employee's Insurance section for more information about portability. 16

19 DEFINITIONS ReliaStar Life ReliaStar Life Insurance Company, at its Home Office in Minneapolis, Minnesota. Spouse your legal husband or wife. The term "spouse" does not include a domestic partner. Terminal Condition an injury or sickness which is expected to result in your death within 12 months and from which there is no reasonable chance of recovery. ReliaStar Life, or a qualified party chosen by ReliaStar Life, will make this determination. Total Disability, Totally Disabled your inability, due to sickness or accidental injury, to work at or perform the material and substantial duties of any job suited to your education, training or experience. Written, In Writing signed, dated and received at ReliaStar Life's Home Office in a form ReliaStar Life accepts. You, Your an employee insured for Employee's Insurance under the Group Policy. 17

20 SECTION II DISABILITY INCOME INSURANCE 18

21 RELIASTAR LIFE INSURANCE COMPANY Minneapolis, Minnesota ReliaStar Life Insurance Company (ReliaStar Life) certifies that it has issued the Group Policy listed below to the Policyholder. All benefits are controlled by the terms and conditions of the Group Policy. The Group Policy is on file in the Policyholder's office. You may look at the Group Policy there. Group Policy Number Policyholder DISABILITY Kalispell School District #5 The certificate summarizes and explains the parts of the Group Policy which apply to you. This certificate is not an insurance policy. In any case of differences or errors, the Group Policy rules. This certificate replaces any other certificates ReliaStar Life may have given you under the Group Policy. Registrar 19

22 SCHEDULE OF BENEFITS Disability Income Insurance Monthly Income Benefits Monthly Income Benefit Percentage... 60% Maximum Monthly Income Benefit... $3,000 Minimum Monthly Income Benefit... $100 The Monthly Income Benefit is calculated as follows: Monthly Income Benefit (A divided by B) times C, minus Other Income. A = your Basic Monthly Earnings minus Recovery Work Earnings. B = your Basic Monthly Earnings. C = your Gross Monthly Benefit, defined as follows: Take the Benefit Percentage and multiply by your Basic Monthly Earnings. Compare this result to the Maximum Monthly Income Benefit and take the lesser of the two amounts. Other Income is described in the Disability Income Insurance section of the certificate. Recovery Work Earnings is defined in the Definitions section of the certificate. In no event will your Monthly Income Benefit plus Other Income be greater than your predisability Basic Monthly Earnings. Basic Monthly Earnings your monthly salary or wage on the day before the date you became disabled. It does not include bonuses, commissions or overtime pay. Benefit Waiting Period Your benefit waiting period is the later of the following: The date your benefits under any salary continuance or short term disability plan sponsored by the Policyholder terminate. The date your accumulated sick leave days provided by the Policyholder are exhausted. 60 days of disability. Maximum Benefit Period Age at disability Less than and over Maximum benefit period To age 65, or 3 years 6 months, if longer. 3 years, 6 months 3 years 2 years 6 months 2 years 1 year 9 months 1 year 6 months 1 year 3 months 1 year 20

23 EMPLOYEE'S INSURANCE Eligibility You are eligible on the later of the following dates: The Group Policy's Effective Date, October 1, The first day of the month on or after the date you start continuous service with the Policyholder. You must meet the following conditions to become insured: Be eligible for the insurance. Be actively at work. Effective Date of Employee's Insurance Your insurance starts on the later of the following dates: The date you become eligible. The date you return to active work if you are not actively at work on the date insurance would otherwise start. Exception: Your insurance starts on a nonworking day if you were actively at work on your last scheduled working day before the nonworking day. Continuity of Coverage If you are not actively at work on the date insurance would otherwise start, ReliaStar Life will waive the actively at work requirement if both of the following are true: You are eligible for insurance except for meeting the actively at work requirement on the Group Policy's Effective Date. You were covered under the Policyholder's prior group disability income plan on the day before the Group Policy's Effective Date. Your insurance is subject to payment of premium. Before you return to active work, any benefit will be limited to the amount that would have been paid under the prior plan. ReliaStar Life reduces the amount it pays by any amount for which the prior plan is liable. Your insurance will stop on the date benefits would have ended under the prior plan had it remained in force. If you were actively at work and insured under the Group Policy on its Effective Date, and you were covered under the Policyholder's prior group disability income plan on the day before that date, then ReliaStar Life applies the pre-existing condition provision to your benefits as follows: 1. If you fully satisfy the Group Policy's pre-existing condition provision, then benefits are payable according to the terms of the Group Policy. 2. If you become disabled due to a pre-existing condition before you have satisfied the Group Policy's pre-existing condition provision, ReliaStar Life will look at whether you would have satisfied the prior plan's pre-existing condition provision. If the prior plan did not have a pre-existing condition provision, ReliaStar Life will credit the time you were covered under the prior plan toward the Group Policy's pre-existing condition provision. If you fully satisfied the prior plan's pre-existing condition provision and would have been eligible for benefits under the prior plan, then ReliaStar Life will pay the lesser of the amount payable under the Group Policy or the amount that would have been payable under the prior plan. Benefits will stop on the earlier of the date benefits end under the Group Policy or would have ended under the prior plan. If you did not fully satisfy the prior plan's pre-existing condition provision and would not have been eligible for benefits under the prior plan, then ReliaStar Life will credit any time you satisfied under the prior plan's pre-existing condition provision toward meeting the Group Policy's pre-existing condition provision. On the Group Policy's Effective Date, if the maximum benefit is greater under the Group Policy than under the Policyholder's prior plan, then the Group Policy's pre-existing condition provision will apply to any increased benefit amount. Please refer to the Exclusions in the Disability Income section of the certificate for more information on pre-existing conditions. 21